Thursday, July 31, 2014

On pain

Janice Lynch Schuster offers first-hand advice on ways of managing chronic pain, here.  She notes:

I am not my pain. I am a wife, mother, worker, writer, sister, daughter and friend. My world is rich and rewarding. I want for nothing – save pain relief.  In fact, although the pain may be a permanent fixture, the sensation is impermanent.  Some days are better than others.  I must choose how much I want to let it control my experience—or how much I want to control it.

Powerful and helpful, both, for you or a loved one.

Wednesday, July 30, 2014

Tom's Reason to Ride is back

With great disappointment, I sadly announce that “A Reason To Ride’s” founder, Tom DesFosses’ cancer is back.  While Tom started to "A Reason to Ride" because he wanted to give back and raise funds for research he never made the Ride about himself.  Tom founded the ride because many of us have reasons to ride.  His energy and enthusiasm persuaded me to give full logistical support to the ride when I was running the hospital. Now, the ride is run solely by Tom and his friends, with tremendous support from Fuddruckers restaurants and the other firms noted below.

We still have reasons to ride, and it’s never been more important than now to ride.  I hope you'll join me on September 7 in Danvers, MA.  Here is Tom in his own words:

Why A Reason To Ride? I have a new reason, personal as it is. I have just been re-diagnosed with brain cancer. This year was to be my 10th year cancer free, but alas it came back in spades. A few weeks ago I visited BIDMC for my yearly check up and a MRI.  For the past nine years we looked at the MRI and smiled and then said "See you next year." Not so this time, the cancer has returned BIG time. Since that Thursday my life has been a blur: Thursday blood work, Friday more MRI’s and body scans, Monday spinal tap, Tuesday out-patient chemo, Wednesday in patient chemo, released Sunday, sick and tired as hell up to Thursday, start the whole process again next Tuesday for at least 4 more times. Then what, probably every other month for a year and a half, then?

If you’re wondering if I am upset, sure I am, because most of the research funding is raised by groups like ours and we don’t have the full support Federally to fund all the medical research necessary to find a cure.  This is why I started the event and why your support is so important to OUR fight. 

Remember, “A Reason To Ride” is 100% grass roots with 100% of funds going towards research.

Finally, I’m asking for your help, not for me, but for our future.  Please forward this email to your friends, ask them to ride, ask them to donate and spread the message.  Yell out your reason to ride and join us on September 7 as we fight cancer together.

Click here to register or donate

Thanks for your time and helping us fight cancer.
Tom DesFosses
A Reason To Ride

Them's fighting words!

Gary Schwitzer offers a front-row seat to some conflicting claims.  It all starts with a news release from robotic surgeon David Samadi at New York's Lenox Hill Hospital that was picked up by the American Urological Association (AUA):

According to a new study from Detroit, Michigan, robotic prostatectomy yields highly successful long-term prostate cancer results. In fact, nearly all — 98.8% — of the patients remained prostate cancer survivors at ten years post-surgery; results comparable to the more invasive surgical method used in the past.

Oncologist Richard Hoffman replies:

“The AUA does misrepresent the data.  The 98.8% refers to the proportion of subjects who had not died from prostate cancer.  Only 73.1% were biochemically free of cancer, meaning that the rest had a rising PSA suggesting cancer progression/recurrence.  

The observational design means that investigators cannot make any meaningful comparisons of robotic surgery results with those obtained by open prostatectomy,  Thus, Samadi’s comment that robotic prostatectomy is “a preferred treatment” is not based on convincing evidence, just on the “preferences” of surgeons and patients who see the surgeons’ ads. 

Them's fighting words! Gary says, "Let’s see how the urologists duke it out." One already expressed some thoughts on Twitter.

So you think you can multi-task

A friend of mine was excitedly discussing her job with a high-tech firm.  "Our meetings are so great and vibrant.  While the sessions are going on, we are all on our computers multi-tasking.  It's so efficient!"

Well, no.  There's a lot of evidence that constant interruptions do not improve efficiency and that they also impair quality.  Here's a recent example, published in Human Factors.  It focused solely on interruptions during the course of writing and concluded:

Our research suggests that interruptions negatively impact quality of work during a complex, creative writing task. 

Observing observation status

Brad Flansbaum offers this interesting post about the ambiguities and uncertainties inherent in the current Medicare "two-midnight rule."  He refers to a recent white paper prepared by a group of hospitalists:

Months of work have led us to our white paper, entitled, The Observation Status Problem: Impact and Recommendations for Change. The release utilizes a multidimensional data set of significant size and includes a finding synthesis.  It is our hope to use the information we collected to inform Congress, CMS, media, and members on the somewhat chaotic understanding of observation status policy. 

This is well done and thoughtful and could be of assistance to federal policy makers, if they take the time to read and listen.  Look at this portion of the introduction:

The intricacies of observation policy have created a situation where observation care is now commonly being delivered on hospital wards, indistinguishable from inpatient care. The frequency and duration of observation status has also grown significantly in recent years, well beyond its original intent. This is important because observation is not covered by Medicare Part A hospital insurance, and patients under observation are ineligible for skilled nursing facility (SNF) coverage at discharge, which may leave them vulnerable to additional complications.

The results:

--Lack of knowledge and confidence in implementing the two-midnight rule
--Disruptions to hospitalist and hospital workflow
--Decrease in the ability of hospitalists to make independent clinical decisions
--Negative impacts on patients, including access to SNF coverage and highly variable financial liabilities 
--Damage to the physician-patient relationship

Tuesday, July 29, 2014


Earlier this month, Modern Healthcare published a story about the slow movement by hospitals to prevent operating room fires. An excerpt:

Despite a slew of news accounts about patients being set on fire in operating rooms across the country, adoption of precautionary measures has been slow, often implemented only after a hospital experiences an accident. Advocates say it's not clear how many hospitals have instituted the available protocols, and no national safety authority tracks the frequency of surgical fires, which are thought to injure patients in one of every three incidents. About 240 surgical fires occur every year, according to rough estimates by the ECRI Institute, a not-for-profit organization that conducts research on patient-safety issues. But fires may be underreported because of fear of litigation or bad publicity. 

“Virtually all surgical fires are preventable,” said Mark Bruley, vice president of accident and forensic investigation for ECRI, which has been tracking operating-room fires for 30 years. He blames the persistence of the problem on the slow migration of best practices across the hospital industry.  

Most surgical fires involve the ignition of concentrated oxygen by electrosurgical tools used in upper-body procedures, where patients receive the highly flammable gas through face masks and nasal devices. But a growing number are linked to the ignition of alcohol-based antiseptics.

Solid numbers on the incidence of operating-room fires do not exist. ECRI's latest estimate of 240 operating-room fires each year between 2004 to 2011 was revised down from earlier estimates of 650 fires a year between 2004 to 2007. 

While that suggests there has been improvement, studies of anesthesia malpractice claims suggest there's been a rise in incidents. “There is an inherent problem in preventing relatively rare events,” said Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority. People think “it is not likely to happen to you in particular,” he said.

I was surprised and contacted a patient safety expert who replied, "No one believes it can happen to them, so they cut corners."

That seems to be the case in lots of places.  From the article:

Many of the best fire-safety practices developed in recent years stem from the work at Christiana Care Health System, Newark, Del., after two patients caught fire in operating rooms within eight months in 2003.

They pioneered their own process, which involves discussing the risk of fire during the scheduled time-out before surgery. The hospital hasn't burned a patient since.

Protocols like Christiana's have been widely disseminated. Yet, Christiana says it still get calls several times a month from hospitals that are just starting to implement a system. “It's a bit of an uphill slog,” said Dr. Kenneth Silverstein, chairman of Christiana's department of anesthesiology. “The bottom line is, in order to have a culture of safety in your institution, you have to get people behind it.” 

Sounds familiar.  We saw (and still see) hospitals go through the same slow process with central line infections, ventilator associated pneumonia, and other infection-related problems.  Maybe now it's time to yell, "Fire!"

2008 graphic from

Debunking the debunking

I really don't want to write more about surgical robots, but you folks out there keep sending good material.  Here's an article by a surgeon on "debunking the myths about robotic surgery."

Let's look some assertions:

The robotics technology is expensive and the whole surgical team has to be trained, which can add to the cost. But there’s also a tremendous savings compared with traditional surgery because the patient is out of the hospital more quickly and there are fewer complications.

Many times, the robotics-assisted procedures can be done much more quickly, so there’s less risk simply because the duration of the procedure is shorter. You also have the smaller incisions, and less bleeding, factors that reduce the risks.

This kind of fast and loose talk is a discredit to the profession. I wish there were an agreement that we would rely solely on sound research studies instead of this anecdotal tripe.

Will you be in Panama City in August?

This is a must-see exhibit by the Smithsonian Tropical Research Institute.  A good chance to meet Matt Larsen, STRI’s new director, too.

Keeping up with the Joneses

Just by casual observation, I have asserted that a hospital was more likely to acquire a surgical robot if a nearby competitor hospital had already done so.  But this was an untested conclusion, based on viewing websites and highway signs, particularly from community hospitals, like above.  So I was intrigued to see this great article by Huilin Li (Department of Population Health, New York University) and others in Healthcare.  From the abstract:


The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a “medical arms race” influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one.


We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the “neighborhood effect” on the acquisition of the surgical robot while adjusting simultaneously for known confounders.


After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot (OR=1.71, 95% CI: 1.07–2.72, p=0.02).


There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.